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1 L1l;C1ltZl+th'tfi Ci'Ct GL CZ l�It C2 N li tD 11 l3 C2 tt tt ty.06 lY l7.CtA4`tvfe.t, <br /> r IPPLICITION FOR PERMIT k SIN JOAQUIN LOCIL HEALTH DISTRICTk: <br /> !: UNDERGROUND TANK t 1601 B BAKILTOI AVE., STOCKTON Cil: <br /> t: CLOSURE OR 11111DONMEIT t Telephone (2011 168-3120 t: <br /> M41 1:9V k1 t101 t1 t1 Ct1 k1 t1 t1 C1l1 tZ C;C1l1 t1 tt 11 t1 C1lt lk ti C1 t1 k1 C1l1 <br /> APPLICATION FOR PBAMANBNT/tBMPORiR+ CLOSUIB OP UNDERGROUND HAIIRDOUS SUBSTINCES STORIGE FICILITY <br /> THIS PERMIT BIPIRBS 90 DIPS FROM THE IPPROVIL DATE. DO NOT 11178 IN 111 SHADID AREAS. INDICATE PERMIT TYPE BELOW: <br /> X REMOVAL TEMPORARY CLOSURE — ABANDONMENT IN PLACE <br /> 8PA SITE I PROJECT COMTICT I TELEPHONE I Rudy Rodriguez <br /> CAC000186903 (209) 468-3066 <br /> 1 FACILITY MAKE Harney Lane Sanitary Landfill PHONE 1 (209) 368-4525 <br /> 1 - ----- <br /> C 1DDRESS 14750 Harney Lane, Lodi California <br /> 1 - <br /> L CROSS STREET between Eberhard and Tully Roads <br /> 1 — <br /> T OINER/OPERITOR San Joaquin County Public Works PHONE 1 (209) 468-3066 <br /> Y <br /> C CONTRICTOR MINE Se / _ PHONE I <br /> 0 <br /> I COYTRICTOR IDDRBSS CI LIC 1 CUSS <br /> T —--- -- <br /> R INSURER WORK.COMP.1 <br /> A - <br /> C FIRE DISTRICT Linden-Peters PERMIT 1/[WSPTR <br /> T — <br /> 0 LIBORATORY MANE California Water Labs PNOHE 1 (209) 527-4050 <br /> R <br /> SIMPLING PIR0 SIMPLING METIOD As specified <br /> TANK ID I TABK SI21 CHEMICILS STORED CURRENTLI CHEMICALS STORED PRIVIOUSL <br /> T <br /> 1 39-__ ISS=OL_ 5,000 gal Empty Diesel Fuel <br /> K 39- <br /> LIST IDDITIONIL TANK INFORHITIOB AS NEEDED OI SEPARATE FOIL <br /> NNVItlIr1NIIINMNRNSDBNWYtl11YWX4NIpptlN11DS8Y NYNWOIYNIHH01NR7WRIpNJFWWISIgIbIYYNIIYWYMkYISCYIHtlNNUCYYJNYIiWgX4tll!IYC4NN11NIY!1WUOYWCWYGRININDNNYIOYWtNV1 <br /> P IPPROVED _ APPROVED WITH CONDITIONS DISAPPROVED <br /> L �� — (S88 1fifACIIMBNT NIT CONDITIONS)— / y <br /> 1 PL/N RBVIIWERS NAME <br /> 1 i �'L — __D►TB YL 1—/— <br /> /J / <br /> APPLICANT MUST PERFORM ILL WORK 11 ACCORDINCE WITH SIN JOIOUIN COUNTY ORDINANCES, STATE LAWS, IND RULES IND REGULITIONS <br /> OF THE SIN JOAOUII LOCAL HEALTH DISTRICT. OWNER OR LICENSED AGENT'S SIGMITURS CERTIFIES THE FOLLOWING: 11 CERTIFY THAT <br /> IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY INY PERSON IN SUCH HAMMER IS TO BECOM <br /> SUBJECT TO WORKER'S COMPBNSITIOM LIVS OF CILIFORNII.1 CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE <br /> FOLLOVING: 11 CERTIFY ?HIT IN THE PERFORMIMCE OF THE WORK FOR WITCH THIS PERMIT 13 ISSUED, I SHALL EMPLOY PERSONS SUBJRC <br /> TO WORKER'S COMPENSATION LITS OF CALIFORWII. <br /> FOR IN TIONS AT LEAST 90 HOURS IN ADVANCE <br /> SIGNED = <br /> _ �i— — --_ DiT6 � <br /> OFFICE USE ONLY--EH V1 016 12/81 <br /> SSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSSISSSS <br /> SIREPS I I COMP I ILOC CODE DIST CODS' MOUNT OUR AMOUNT RCVD I CKI/CISO I RCVD 81 1 Dill RCVD I PERMIT I <br />